PAIN RELIEF CENTER SPECIFIC FORM
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- Bernadette Allen
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1 PAIN RELIEF CENTER SPECIFIC FORM Legal Name: Referring Specialist: CONCERNS Thank you for taking the time to fill out this intake form. We know it is comprehensive, but by gathering this information about your health history and goals helps provide your naturopathic doctors a more complete understanding of you. We want to help you reach your optimal health. Most important concern you would like to address? Additional concerns? HISTORY OF PRESENT ILLNESS What caused your illness? (Please check all that apply.) Injury at work Motor Vehicle Accident Injury at home Infection Following illness Poisoning Following surgery Herpes zoster (Shingles) Burn cause After dental care How often do you have pain? Constant Nearly Constant Fairly Constant Frequently Intermittent (100% of the time) (80-90% of the time) (50-80% of the time) (25-50% of the time) (Less than 25% of the time) Other: Approximate date of original onset/injury: PAGE 1
2 PAIN SCALE Circle ( ) the number that describes your pain level on a GOOD day and place a square ( ) around the number that describes your pain on a BAD day. EMPLOYMENT Type of work: Years on the job: Workman s Compensation: Case Workers Name: Does your pain keep you for working? Retired Is there litigation involved? Case Number: PAGE 2
3 LOCATION OF PAIN Please mark the diagram below indicating the TYPE of pain(s)/sensations(s) you are having and the location on your body. Please use the following symbols: Solid Circles for Stabbing Pain Open Circles for Pins & Needles Circles with X s X for Numbness X s for Burning Pain Triangles for Aching Pain DESCRIPTION OF PAIN Describe your pain in each of your troubled areas. Use the following descriptors: Aching, Annoying, Burning,, Constant, Cramping, Dull, Heavy, Hot, Intense, Numbing, Radiating, Sharp, Shooting, Sore, Stabbing, Stinging, Tight, Tingling, Transient, Unbearable. Example: Knee Aching, Annoying, Constant, Sore, Dull AREA OF MOST CONCERN: SECOND AREA: THIRD AREA: PAGE 3
4 ACTIONS THAT MODIFY PAIN For each area of pain, please mark (+) Increases pain, (-) decreases pain, or leave blank for no change or no effect. AREA OF MOST CONCERN: SECOND AREA: THIRD AREA: If necessary, please write down other activities not listed and specify if they increase or decrease your pain: PAIN MEDICATION Please list the PAIN medicines you are currently taking. List your other medicines in the next section. I do not take medicine for pain. MEDICINE STRENGTH TIMES/DAY FIRST TAKEN PRESCRIBER EFFECTIVE? PAGE 4
5 Please list other pain medicines you have tried, but no longer take, for your PAIN. MEDICINE STRENGTH TIMES/DAY FIRST TAKEN PRESCRIBER EFFECTIVE? Please check any over-the-counter medicines you take. ne /Cough medicine Laxatives Antacids Eye Drops Sleep Medicine Aspirin containing products Herbal / Homeopathic Remedies Vitamins Bowel products Other: Have you taken cortisone or other steroid medicine within the last year? If Yes, which drug and what reason? Was it effective? Are you on any anticoagulant(s)/anti-platelet/blood thinner(s) e.g., aspirin, Coumadin, ibuprofen, Plavix? If Yes, please write drug information below. Date of last blood test: MEDICINE STRENGTH TIMES/DAY REASON FOR TAKEN PRESCRIBER ADDITIONAL INFORMATION Do you have any other current medical problems or personal issues that need to be addressed? If yes, please describe: The information provided above is correct to the best of my knowledge. Print Patient Name Patient or legally authorized individual signature Printed legally authorized individual name MR Number (Office Use Only) Date Relationship (parent, legal guardian, personal representative, etc.) PAGE 5
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